Stroke is a big, growing and costly problem. There are 550,000 first time and recurrent stroke survivors each year in the United States, costing an estimated 57.9 billion dollars for 2006. About one third of stroke survivors return to driving, most with little or no formal assessment or training. Although strokes are associated with significant neurological impairments affecting driving performance, few tools are available in the rehabilitation setting for retraining driving skills and abilities after stroke. Driving simulations have been used to assess driver fitness, but there is little evidence that they are effective in training driving-related skills and abilities after stroke. We will test the hypothesis that combining driving simulator training with usual ambulatory post-stroke care improves the potential for driving resumption after stroke more than usual care alone. Driving simulator training is an interactive task that is thought to take advantage of residual neuroplasticity after stroke by stimulating cortical reorganization in a context relevant manner. The goal of this Phase I study is to develop two reliable driving simulation scenarios as a training method to improve upon traditional rehabilitation post-stroke care for patients who want to drive again. After a first time stroke, patients who are judged to be "temporally unfit" for driving will receive usual post-stroke care (traditional occupational, physical and speech therapy and 12 hours of general classroom training about healthy life-style choices.) In addition, each stroke patient will receive 12 hours of training on a driving simulator before they participate in a standard behind the wheel, on road test. 20 to 30 stroke patients will be tested within this context. In addition, 15 normal drivers will also be tested on the simulator in order to evaluate the performance and test-retest variability of the simulator. The main outcome measure is a "pass/fail" rating on a behind the wheel road test. Reliability of the scenarios will be tested and a scoring system will be developed to quantify the results of driving simulation performance in patients with varying skills and abilities after stroke. It is expected that Phase I results will justify a Phase II study for validation in a larger cohort of stroke patients and the development of normative data. At the completion of Phase II, validated simulator scenarios and normative data will be packaged as a plug in to the STISIM Drive driving simulator and marketed and sold to rehabilitation clinics and occupational therapists who deal primarily with stroke patients. PUBLIC HEALTH RELEVANCE: There are 550,000 first time and recurrent stroke survivors each year in the United States and about one third return to driving, most with little or no formal assessment or training. Despite the need for driver retraining after stroke, simple and practical context-relevant tools are not available in the rehabilitation setting. The goal of our research is to develop two commercially viable driving simulation scenarios to improve the effectiveness of driver rehabilitation training in patients wishing to resume driving after stroke.